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Safety, Reliability, Human
Factors, and Human Error
in Nuclear Power Plants

B.S. Dhillon
 Safety, Reliability,
Human Factors, and
Human Error in
Nuclear Power Plants
 Safety, Reliability,
Human Factors, and
Human Error in
Nuclear Power Plants

B.S. Dhillon
Department of Mechanical Engineering
University of Ottawa
Ottawa, Canada
CRC Press
Taylor & Francis Group
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© 2018 by Taylor & Francis Group, LLC

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This book is affectionately dedicated to my son-in-law Mandeep.
Contents

Preface......................................................................................................................xv
Author.................................................................................................................... xix

1. Introduction......................................................................................................1
1.1 Background............................................................................................. 1
1.2 Safety, Reliability, Human Factors, and Human
Error-Related Facts, Figures, and Examples.......................................1
1.3 Terms and Definitions...........................................................................3
1.4 Useful Information on Safety, Reliability, Human Factors,
and Human Error in Nuclear Power Plants....................................... 4
1.4.1 Books..........................................................................................5
1.4.2 Journals...................................................................................... 6
1.4.3 Conference Proceedings..........................................................7
1.4.4 Technical Reports...................................................................... 8
1.4.5 Data Sources.............................................................................. 9
1.4.6 Organizations............................................................................9
1.5 Scope of the Book................................................................................. 10
1.6 Problems................................................................................................ 11
References........................................................................................................ 12

2. Basic Mathematical Concepts..................................................................... 15

2.1 Introduction.......................................................................................... 15
2.2 Arithmetic Mean and Mean Deviation............................................. 15
2.2.1 Arithmetic Mean..................................................................... 16
2.2.2 Mean Deviation....................................................................... 16
2.3 Boolean Algebra Laws......................................................................... 17
2.4 Probability Definition and Properties............................................... 18
2.5 Useful Mathematical Definitions....................................................... 20
2.5.1 Definition I: Cumulative Distribution Function................. 20
2.5.2 Definition II: Probability Density Function........................ 21
2.5.3 Definition III: Expected Value............................................... 21
2.5.4 Definition IV: Laplace Transform.........................................22
2.5.5 Definition V: Final Value Theorem Laplace Transform..... 23
2.6 Probability Distributions.................................................................... 24
2.6.1 Binomial Distribution............................................................ 24
2.6.2 Exponential Distribution....................................................... 25
2.6.3 Rayleigh Distribution............................................................. 26
2.6.4 Weibull Distribution............................................................... 27
2.6.5 Bathtub Hazard Rate Curve Distribution........................... 27

vii
viii Contents

2.7 Solving First-Order Differential Equations Using Laplace

Transforms............................................................................................ 28
2.8 Problems................................................................................................30
References........................................................................................................ 30

3. Safety, Reliability, Human Factors, and Human Error Basics.............. 33

3.1 Introduction.......................................................................................... 33
3.2 Safety Management Principles and Safety and Engineers............34
3.3 Accident Causation Theories.............................................................. 35
3.3.1 The Domino Theory............................................................... 35
3.3.2 The Human Factors Theory.................................................. 37
3.4 Bathtub Hazard Rate Curve............................................................... 38
3.5 General Reliability Formulas............................................................. 40
3.5.1 Failure (or Probability) Density Function........................... 40
3.5.2 Hazard Rate (Time-Dependent Failure Rate) Function.... 40
3.5.3 General Reliability Function................................................. 41
3.5.4 Mean Time to Failure.............................................................42
3.6 Reliability Networks............................................................................43
3.6.1 Series Network........................................................................43
3.6.2 Parallel Network..................................................................... 46
3.6.3 k-out-of-n Network.................................................................. 48
3.6.4 Standby System....................................................................... 50
3.6.5 Bridge Network....................................................................... 52
3.7 Human Factor Objectives and Typical Human Behaviors............. 53
3.8 Human Sensory Capacities................................................................54
3.9 Useful Human Factor-Related Guidelines....................................... 55
3.10 Useful Mathematical Human Factor-Related Formulas................ 56
3.10.1 Formula I: Inspector Performance........................................ 56
3.10.2 Formula II: Character Height................................................ 57
3.10.3 Formula III: Rest Period......................................................... 57
3.10.4 Formula IV: Glare Constant................................................... 58
3.11 Reasons for Human Error Occurrence and Types of
Human Errors....................................................................................... 58
3.12 Problems................................................................................................ 60
References........................................................................................................ 61

4. Methods for Performing Safety, Reliability, Human Factors,

and Human Error Analysis in Nuclear Power Plants............................63
4.1 Introduction..........................................................................................63
4.2 Technique of Operations Review (TOR)...........................................64
4.3 Root Cause Analysis (RCA)................................................................65
4.4 Interface Safety Analysis (ISA)........................................................... 66
4.5 Task Analysis........................................................................................ 67
4.6 Hazards and Operability Analysis (HAZOP)................................. 68
4.7 Pontecorvo Method.............................................................................. 69
Contents ix

4.8 Failure Modes and Effect Analysis (FMEA).................................... 71

4.9 Man-Machine Systems Analysis........................................................ 72
4.10 Maintenance Personnel Performance Simulation
(MAPPS) Model.................................................................................... 73
4.11 Fault Tree Analysis (FTA)................................................................... 74
4.11.1 Fault Tree Probability Evaluation......................................... 76
4.11.2 FTA Benefits and Drawbacks................................................ 78
4.12 Markov Method.................................................................................... 79
4.13 Probability Tree Method..................................................................... 82
4.14 Problems................................................................................................84
References........................................................................................................ 85

5. Human Reliability Analysis Methods for Nuclear

Power Stations................................................................................................ 89
5.1 Introduction.......................................................................................... 89
5.2 Incorporation of the HRA Integrally into a Probabilistic
Risk Assessment (PRA) and Human Reliability Method
Requirements........................................................................................ 89
5.3 HRA Process Steps and Their End Results...................................... 91
5.4 HRA Methods....................................................................................... 91
5.4.1 Success Likelihood Index Method–Multiattribute
Utility Decomposition (SLIM-MAUD)................................. 93
5.4.2 Technique for Human Error Rate Prediction (THERP)...... 94
5.4.3 Accident Sequence Evaluation Program (ASEP)................ 95
5.4.4 A Technique for Human Event Analysis (ATHEANA)...... 95
5.4.5 Human Error Assessment and Reduction Technique
(HEART)................................................................................... 97
5.4.6 Cognitive Reliability and Error Analysis Method
(CREAM).................................................................................. 98
5.4.7 Standardized Plant Analysis Risk–Human
Reliability Analysis (SPAR-HRA)....................................... 100
5.5 Problems.............................................................................................. 102
References...................................................................................................... 102

6. Safety in Nuclear Power Plants................................................................ 105

6.1 Introduction........................................................................................ 105
6.2 Nuclear Power Plant Safety Objectives........................................... 105
6.3 Nuclear Power Plant Fundamental Safety Principles................... 106
6.3.1 Management Responsibilities............................................. 106
6.3.2 Strategy of Defense in Depth.............................................. 107
6.3.3 General Technical Principles............................................... 107
6.4 Nuclear Power Plant Specific Safety Principles............................. 108
6.4.1 Siting....................................................................................... 109
6.4.2 Design..................................................................................... 109
6.4.3 Manufacturing and Construction...................................... 110
x Contents

6.4.4 Commissioning..................................................................... 110

6.4.5 Operation............................................................................... 111
6.4.6 Accident Management......................................................... 112
6.4.7 Decommissioning................................................................. 112
6.4.8 Emergency Preparedness.................................................... 113
6.5 Management of Safety in Nuclear Power Plant Design............... 113
6.6 Safety-Related Requirements in the Design of Specific
Nuclear Plant Systems....................................................................... 114
6.7 Deterministic Safety Analysis for Nuclear Power Plants............ 117
6.7.1 Deterministic Safety Analysis Application Areas........... 117
6.8 Nuclear Power Plant Safety-Related Documents and
Standards............................................................................................ 118
6.9 Problems.............................................................................................. 120
References...................................................................................................... 121

7. Nuclear Power Plant Accidents................................................................. 123

7.1 Introduction........................................................................................ 123
7.2 The International Nuclear Event Scale (INES)............................... 123
7.3 World Nuclear Power Plant Accidents’ Fatalities, Rankings,
and Costs............................................................................................. 124
7.4 Three Mile Island Accident.............................................................. 127
7.4.1 Radiological Health Effects................................................. 128
7.4.2 The Three Mile Island Reactor No. 2 Cleanup................. 128
7.4.3 The Accident’s Effect on the Nuclear Power Industry.... 128
7.5 The Chernobyl Accident................................................................... 128
7.5.1 Dispersion and Disposition of Radionuclides.................. 129
7.5.2 Operator Error....................................................................... 129
7.6 The Fukushima Accident.................................................................. 129
7.7 Lessons Learned from the Three Mile Island, Chernobyl,
and Fukushima Accidents................................................................ 130
7.8 Comparison of the Chernobyl and Three Mile Island
Accidents and of the Fukushima and Chernobyl Accidents....... 131
7.9 Problems.............................................................................................. 132
References...................................................................................................... 133

8. Reliability and Maintenance Programs for Nuclear Power Plants....... 135

8.1 Introduction........................................................................................ 135
8.2 A Reliability Program’s Objectives and Requirements................ 135
8.3 Guidance for Developing Reliability Programs............................ 137
8.3.1 Using Systematic Approaches for Identifying and
Ranking SIS........................................................................... 138
8.3.2 Specifying Reliability-Related Targets............................... 138
8.3.3 Highlighting and Describing Potential Failure Modes.......139
8.3.4 Stating Minimum Capabilities and Levels of
Performance........................................................................... 139
Contents xi

8.3.5Maintenance Program.......................................................... 139

8.3.6Inspections, Tests, Modeling, and Monitoring................. 140
8.3.6.1 Providing for Inspections and Tests................... 140
8.3.6.2 Modeling................................................................ 140
8.3.6.3 Monitoring Performance and Reliability........... 140
8.3.7 Implementing a Reliability Program................................. 140
8.3.8 Recording and Reporting Results of Reliability
Program-Related Activities................................................. 140
8.3.9 Documenting a Reliability Program.................................. 140
8.4 A Maintenance Program’s Objectives, Scope, and Background. 141
8.5 Guidance for Developing Maintenance Programs....................... 141
8.5.1 Program Basis........................................................................ 141
8.5.2 Maintenance Organization.................................................. 143
8.5.3 Maintenance Activities........................................................ 144
8.5.4 Structure, System, or Component Monitoring................. 145
8.5.5 Maintenance Work................................................................ 146
8.5.6 Spare Parts and Procurement............................................. 147
8.5.7 Management Assessment and Program Review............. 147
8.5.8 Record Keeping..................................................................... 148
8.6 Reliability and Maintenance Program-Related Standards.......... 148
8.7 Problems.............................................................................................. 149
References...................................................................................................... 150

9. Human Factors and Human Error in Nuclear Power Generation...... 151

9.1 Introduction........................................................................................ 151
9.2 Aging Nuclear Power Plant Human Factor-Related Issues............151
9.3 Human Factor-Related Issues That Can Have a Positive
Impact on the Decommissioning of Nuclear Power Plants......... 152
9.3.1 Maintaining a Safety Culture............................................. 152
9.3.2 Uncertainty about the Future.............................................. 153
9.3.3 Retaining Organizational Memory.................................... 153
9.3.4 Maintaining Adequate Competence for
Decommissioning................................................................. 154
9.4 Human Factors Engineering Design Goals with Regard to
Nuclear Power Generation Systems and Responsibilities........... 154
9.5 Human Factors Review Guide for ­Next-­Generation Nuclear
Reactors............................................................................................... 155
9.6 Human Error Facts, Figures, and Examples Concerning
Nuclear Power Generation................................................................ 158
9.7 Occurrences Caused by Operator Errors during Operation
in Commercial Nuclear Power Plants............................................. 159
9.8 Causes of Operator Errors in Commercial Nuclear Power
Plant Operations................................................................................. 160
9.9 Problems.............................................................................................. 160
References...................................................................................................... 161
xii Contents

10. Human Factors and Human Error in Nuclear Power Plant

Maintenance................................................................................................. 163
10.1 Introduction........................................................................................ 163
10.2 Study of Human Factors in Power Plant Maintenance................ 163
10.3 Elements Relating to Human Performance That Can
Contribute to an Effective Maintenance Program in Nuclear
Power Plants....................................................................................... 164
10.4 Useful Human Factors Methods to Assess and Improve
Nuclear Power Plant Maintainability............................................. 165
10.4.1 Structured Interviews.......................................................... 165
10.4.2 Task Analysis......................................................................... 166
10.4.3 Surveys................................................................................... 166
10.4.4 Potential Accident/Damage Analysis................................ 166
10.4.5 Critical Incident Technique................................................. 167
10.5 Nuclear Power Plant Maintenance Error-Related Facts,
Figures, and Examples...................................................................... 167
10.6 Causes of Human Error in Nuclear Power Plant
Maintenance and Maintenance Tasks Most Susceptible to
Human Error in Nuclear Power Plants........................................... 168
10.7 Digital Plant Protection Systems Maintenance
Task-Related Human Errors............................................................. 169
10.8 Useful Guidelines for Human Error Reduction and
Prevention in Nuclear Power Plant Maintenance......................... 170
10.9 Methods for Performing Maintenance Error Analysis in
Nuclear Power Plants........................................................................ 171
10.9.1 Markov Method.................................................................... 171
10.9.2 Fault Tree Analysis............................................................... 174
10.9.3 Maintenance Personnel Performance Simulation
(MAPPS) Model..................................................................... 176
10.10 Problems.............................................................................................. 177
References...................................................................................................... 178

11. Human Factors in Nuclear Power Plant Control Systems................... 181

11.1 Introduction........................................................................................ 181
11.2 Human Performance-Related Advanced Control Room
Technology Issues and Control Room Design-Related
Deficiencies That Can Lead to Human Error................................. 181
11.3 Human Engineering Discrepancies in Control Room Visual
Displays............................................................................................... 183
11.4 Human Factor–Related Evaluation of Control Room
Annunciators...................................................................................... 184
11.5 Benefits of Considering Human Factors in Digital Control
Room Upgrades and an Approach for Incorporating Human
Factor Considerations in Digital Control Room Upgrades.......... 186
Contents xiii

11.6 Recommendations for Overcoming Problems When

Digital Control Room Upgrades Are Undertaken without
Considering Human Factors into the Design................................ 187
11.7 Problems.............................................................................................. 190
References...................................................................................................... 190

12. Mathematical Models for Performing Safety, Reliability, and

Human Error Analysis in Nuclear Power Plants.................................. 193
12.1 Introduction........................................................................................ 193
12.2 Model I................................................................................................. 193
12.3 Model II............................................................................................... 197
12.4 Model III.............................................................................................. 199
12.5 Model IV.............................................................................................. 201
12.6 Model V............................................................................................... 204
12.7 Model VI.............................................................................................. 207
12.8 Model VII............................................................................................ 211
12.9 Model VIII........................................................................................... 213
12.10 Problems.............................................................................................. 216
References...................................................................................................... 217

Appendix: Bibliography.................................................................................... 219

Index...................................................................................................................... 241
Preface

Each year billions of dollars are being spent in the area of nuclear power gen-
eration to design, manufacture, operate, and maintain various types of sys-
tems around the globe. In 2011, there were around 436 commercial nuclear
reactors operating in the world that generated about 16% of the world’s
electricity.
Many times, the systems used in nuclear power plants fail due to safety,
reliability, human factors, and human error-related problems. For example,
during the period from 1990–1994, approximately 27% of commercial nuclear
power plant outages in the United States occurred due to human error.
Although over the years a large number of journal and conference proceed-
ings articles related to safety, reliability, human factors, and human error in
nuclear power plants have appeared, there is no book that covers all four of
these topics within its framework to the best of the author’s knowledge. This
causes a great deal of difficulty for information seekers because they have to
consult many different and diverse sources.
Thus, the main objective of this book is to combine all these topics into a
single volume in order to eliminate the need to consult many different and
diverse sources to obtain the desired information. The sources of most of the
material presented are listed at the end of each chapter in the reference sec-
tion. These will be useful to readers if they wish to delve more deeply into a
specific area or topic. The book contains a chapter on mathematical concepts
and another chapter on introductory safety, reliability, human factors, and
human error concepts, which are considered useful for understanding the
content of subsequent chapters. Furthermore, two more chapters are devoted
to methods considered useful for performing safety, reliability, human ­factor,
and human error analyses concerning nuclear power plants.
The topics covered in the book are treated in such a manner that the reader
will require no previous knowledge to understand the contents. At appro-
priate places, the book contains examples along with their solutions, and at
the end of each chapter there are numerous problems to test the reader’s
comprehension in the area. An extensive list of publications dating from
1960–2015 (relating directly or indirectly to safety, reliability, human factors,
and human error in nuclear power plants) is provided at the end of this book
to give readers a view of the intensity of developments in the area.
The book is composed of 12 chapters. Chapter 1 presents the need for
and the background concerning nuclear power plants; nuclear power plant
safety, reliability, human factor, and human error-related facts, figures, and
examples; important terms and definitions; useful sources for obtaining
information on safety, reliability, human factors, and human error in nuclear
power plants; and the scope of the book. Chapter 2 reviews mathematical

xv
xvi Preface

concepts considered useful for understanding subsequent chapters. Some of

the topics covered in the chapter are Boolean algebra laws, probability prop-
erties, probability distributions, and useful mathematical definitions.
Chapter 3 presents various introductory aspects of safety, reliability, human
factors, and human error. Chapter 4 presents a number of methods consid-
ered useful for performing safety, reliability, human factors, and human
error analyses in nuclear power plants. These methods include technique
of operations review, root cause analysis, interface safety analysis, hazards
and operability analysis, failure modes and effect analysis, man-machine
systems analysis, fault tree analysis, the Markov method, and the probabil-
ity tree method. Chapter 5 is devoted to human reliability analysis methods
for nuclear power stations. Some of the methods covered in the chapter are
standardized plant analysis risk–human reliability analysis, the cognitive
reliability and error analysis method, the technique for human event anal-
ysis, the technique for human error rate prediction, and the Human Error
Assessment and Reduction Technique.
Chapter 6 presents various important aspects of safety in nuclear power
plants. Some of the topics covered in the chapter are nuclear power plant
fundamental safety principles, nuclear power plant specific safety principles,
management of safety in nuclear power plant design, safety-related require-
ments in the design of specific nuclear power plant systems, and determinis-
tic safety analysis for nuclear power plants. Chapter 7 is devoted to nuclear
power plant accidents and covers topics such as the Three Mile Island acci-
dent; the Chernobyl accident; the Fukushima accident; lessons learned from
the Three Mile Island, Chernobyl, and Fukushima accidents; and compari-
sons of the Chernobyl and Three Mile Island accidents and of the Fukushima
and Chernobyl accidents.
Chapter 8 presents various important aspects of reliability and mainte-
nance programs for nuclear power plants. Some of the topics covered in the
chapter are reliability program objectives and requirements; guidance for
developing reliability programs; maintenance program objectives, scope,
and background; and guidance for developing maintenance programs.
Chapter 9 is devoted to human factors and human error in nuclear power
generation and covers topics such as aging nuclear power plant human
factor-related issues; human factor-related issues that can have a positive
impact on decommissioning of nuclear power plants; human factors review
guide for next-generation nuclear reactors; human error facts, figures, and
examples concerning nuclear power generation; occurrences caused by oper-
ator errors during operation in commercial nuclear power plants; and causes
of operator errors in commercial nuclear power plant operations.
Chapter 10 presents various important aspects of human factors and
human error in nuclear power plant maintenance. Some of the topics covered
in the chapter are the study of human factors in power plant maintenance;
elements relating to human performance that can contribute to an effec-
tive maintenance program in nuclear power plants; useful human factors
Preface xvii

methods to assess and improve nuclear power plant maintainability; nuclear

power plant maintenance error-related facts, figures, and examples; causes
of human error in nuclear power plant maintenance; useful guidelines for
human error reduction and prevention in nuclear power plant maintenance;
and methods for performing maintenance error analysis in nuclear power
plants.
Chapter 11 is devoted to human factors in nuclear power plant control
­systems and covers topics such as human performance-related advanced
control room technology issues and control room design-related deficien-
cies that can lead to human error, human engineering discrepancies in con-
trol room visual displays, human factor-related evaluation of control room
annunciators, and recommendations for overcoming problems when digital
control room upgrades are undertaken without considering human factors
in the design. Finally, Chapter 12 presents eight mathematical models for
performing safety, reliability, and human error analysis in nuclear power
plants.
The book will be useful to many individuals, including engineering pro-
fessionals working in the area of nuclear power generation; engineering
administrators; engineering undergraduate and graduate students; power
system engineering researchers and instructors; safety, reliability, human
factors, and psychology professionals; and design engineers and associated
engineering professionals.
I am deeply indebted to many individuals, including family members, col-
leagues, friends, and students for their invisible input. The invisible contri-
butions of my children are also appreciated. Last but not least, I thank my
wife, Rosy, my other half and friend, for typing this entire book and for her
timely help in proofreading.

B.S. Dhillon
Ottawa, Ontario, Canada
Author

B.S. Dhillon, PhD, is a Professor of Engineering Management in the

Department of Mechanical Engineering at the University of Ottawa. He
has served as the Chairman/Director of the Mechanical Engineering
Department/Engineering Management Program for over 10 years at the
same institution. He is the founder of the probability distribution named the
Dhillon Distribution/Law/Model by statistical researchers in their publica-
tions around the world. He has published over 234 journal papers and 155
conference proceedings articles on reliability engineering, maintainability,
safety, engineering management, and so on. He is or has been on the edito-
rial boards of 12 international scientific journals. In addition, Dr. Dhillon
has written 45 books on various aspects of health care, engineering manage-
ment, design, reliability, safety, and quality published by Wiley (1981), Van
Nostrand (1982), Butterworth (1983), Marcel Dekker (1984), and Pergamon
(1986), to name a few. His books are being used in over 100 countries, and
many of them have been translated into languages such as German, Russian,
Chinese, and Persian (Iranian).
He has served as General Chairman of two international conferences
on ­reliability and quality control held in Los Angeles and Paris in 1987.
Dr. Dhillon has also served as a consultant to various organizations and bod-
ies and has many years of experience in the industrial sector. He has lectured
in over 50 countries, including keynote addresses at various ­international
scientific conferences held in North America, Europe, Asia, and Africa. In
March 2004, Dr. Dhillon was a distinguished speaker at the Conf./Workshop
on Surgical Errors (sponsored by the White House Health and Safety
Committee and the Pentagon), held on Capitol Hill in Washington, DC.
Dr. Dhillon attended the University of Wales where he received a BS in
electrical and electronic engineering and an MS in mechanical engineering.
He received a PhD in industrial engineering from the University of Windsor.

xix
1
Introduction

1.1 Background
The history of nuclear power plants goes back to 1954, when the first
five megawatt (MW) nuclear plant for generating electricity for commercial
use started to operate at Obnisk, Russia [1]. In 1956, four 50 MW reactors
started to operate at Calder, United Kingdom, and in 1957, a 60 MW pres-
surized light water reactor (PWR) began operation at Shippingport, United
States [1]. Nowadays, as per Reference 2, nuclear power plants generate
about 16% of electricity globally, and there are over 440 commercial nuclear
reactors operating in 30 different countries, with another 65 reactors under
construction.
Needless to say, the systems used in nuclear power plants often fail due
to safety, reliability, human factors, and human error-related problems. For
example, in the United States during the period from 1990–1994, approxi-
mately 27% of commercial nuclear power plant outages were due to human
error [3]. Since 1960, a large number of publications directly or indirectly
related to safety, reliability, human factors, and human error in nuclear
power generation have appeared. A list of over 340 such publications is
­provided in the Appendix.

1.2 Safety, Reliability, Human Factors, and Human

Error-Related Facts, Figures, and Examples
Some of the facts, figures, and examples directly or indirectly concerned
with safety, reliability, human factors, and human error in nuclear power
plants are as follows:

• A study of the commercial nuclear power plant outages in the United

States during the years 1990–1994 reported that about 27% of the
­outages were due to human error [3].

1
2 Safety, Reliability, Human Factors, and Human Error

• A study performed by the U.S. Nuclear Regulatory Commission

(NRC) of licensee reports revealed that around 65% of the nuclear
system failures were due to human error [4].
• As per References 5 and 6, approximately 70% of nuclear power
plant operation-related errors appear to have a human factor-related
origin.
• Approximately 54% of the incidents due to human errors in Japan
during the years 1969–1986 led to automatic shutdowns of nuclear
reactors, and around 15% of those resulted in power reduction [7].
• As per Reference 8, in nuclear power plants in 1985, the distribution
of causes reflected a roughly 50/50 split between equipment-associ-
ated causes versus those attributable to human performance-related
problems; in 1990, human performance-related problems increased
to about 70% of all causes.
• A study of over 4400 maintenance-related history records for the
period from 1992–1994 concerning a boiling water reactor (BWR)
nuclear power plant reported that approximately 7.5% of all failure
records could be clearly attributed to human errors directly or indi-
rectly related to maintenance activities [9,10].
• As per Reference 11, in Japanese nuclear power plants during the
period from 1965–1995, 199 human errors occurred, out of which 50
of them were concerned with maintenance-related tasks.
• During the period from February 1975 to April 1975, a study of 143
occurrences of operating U.S. commercial nuclear power plants
revealed that approximately 20% of the occurrences were due to
operator-related errors [12,13].
• As per References 14 and 15, in South Korean nuclear power plants
during the years 1978–1992, 255 shutdowns occurred, out of which
77 of them were human induced.
• As per Reference 16, a study of major incident/accident reports of
nuclear power plants in South Korea indicated that approximately
20% of the events occurred due to human error.
• In 1989 on Christmas Day in the state of Florida, two nuclear reac-
tors were shut down due to maintenance-related errors and caused
rolling blackouts [17].
• As per Reference 18, in the area of nuclear generation, in 1990, a study
of 126 human error-related significant events revealed that approx-
imately 42% of the problems were directly or indirectly linked to
modification and maintenance.
• As per Reference 19, the Three Mile Island Nuclear Power Plant
accident that occurred in 1979 in the United States was the result of
human-related problems.
Introduction 3

• As per Reference 20, in South Korean nuclear power plants, approxi-

mately 25% of unexpected shutdowns were due to human errors, out
of which over 80% of human errors resulted from usual testing and
maintenance-related tasks.
• As per References 19 and 21, the Chernobyl Nuclear Power Plant acci-
dent in Ukraine in 1986, widely considered as the worst accident in
the history of nuclear power generation, was the result of human-
related problems.

1.3 Terms and Definitions

This section presents some useful terms and definitions directly or indi-
rectly related to safety, reliability, human factors, and human error in nuclear
power plants [21–30].

• Safety: This is conservation of human life and the prevention of

damage to items as per specified mission requirements.
• Reliability: This is the probability that an item/system will carry
out its stated function satisfactorily for the desired period when
used according to the specified conditions.
• Human factors: This is the study of the interrelationships between
humans, the tools they utilize, and the surrounding environment in
which they perform tasks and live.
• Human error: This is the failure to carry out a stated task (or the
performance of a forbidden action) that could result in disruption of
scheduled operations or damage to property and equipment.
• Unsafe condition: This is any condition, under the right set of condi-
tions, that will result in an accident.
• Unsafe act: This is an act that is not safe for an employee/person.
• Safeguard: This is a barrier guard, device, or procedure developed
for protecting humans.
• Hazard: This is the source of energy and the physiological and
behavioral factors which, when uncontrolled, result in harmful
occurrences.
• Accident: This is an event that involves damage to a certain
system that suddenly disrupts the ongoing or potential system
output.
• Failure: This is the inability of a system/item to carry out its stated
function.
4 Safety, Reliability, Human Factors, and Human Error

• Downtime: This is the time during which the system/item is not in

a condition to carry out its specified mission.
• Mission time: This is the element of uptime needed for performing
a stated mission profile.
• Redundancy: This is the existence of more than one means for per-
forming a specified function.
• Useful life: This is the length of time a system/item functions within
an acceptable failure rate level.
• Human performance: This is a measure of actions and failures
under stated conditions.
• Continuous task: This is a task/job that involves some kind of track-
ing activity (e.g., monitoring a changing condition).
• Man function: This is that function which is allocated to the sys-
tem’s human element.
• Unsafe behavior: This is the manner in which an individual carries
out actions that are considered unsafe to himself/herself or other
people.
• Human reliability: This is the probability of accomplishing a task
successfully by humans at any required stage in system opera-
tions within a stated minimum limit (i.e., if the time requirement
is stated).
• Human error consequence: This is an undesired consequence of
human failure.
• Risk: This is a hazardous condition’s probable occurrence rate and
the degree of harm severity.
• Maintenance: This is all actions appropriate for retaining an item/
equipment in, or restoring it to, a stated condition.
• Maintainability: This is the probability that a failed item/system/
equipment will be restored to satisfactory working condition.

1.4 Useful Information on Safety, Reliability, Human

Factors, and Human Error in Nuclear Power Plants
This section lists books, journals, technical reports, conference proceedings,
data sources, and organizations that are directly or indirectly considered
quite useful for obtaining information concerning safety, reliability, human
factors, and human error in nuclear power plants.
Introduction 5

1.4.1 Books
Some of the books that are directly or indirectly concerned with safety, reli-
ability, human factors, and human error in nuclear power plants are listed
below.

• Grigsby, L.E., Editor, Electric Power Generation, Transmission, and

Distribution, CRC Press, Boca Raton, Florida, 2007.
• Cepin, M., Assessment of Power System Reliability: Methods and
Applications, Springer, London, 2011.
• Dhillon, B.S., Power System Reliability, Safety, and Management, Ann
Arbor Science Publishers, Ann Arbor, Michigan, 1983.
• Stephans, R.A., Talso, W.W., Editors, System Safety Analysis Handbook,
System Safety Society, Irvine, California, 1993.
• Dhillon, B.S., Engineering Safety: Fundamentals, Techniques, and
Applications, World Scientific Publishing, River Edge, New Jersey,
2003.
• Cox, S.J., Reliability, Safety, and Risk Management: An Integrated
Approach, Butterworth-Heinemann, New York, 1991.
• Dhillon, B.S., Design Reliability: Fundamentals and Applications, CRC
Press, Boca Raton, Florida, 1999.
• Salvendy, G., Editor, Handbook of Human Factors and Ergonomics, John
Wiley & Sons, New York, 2006.
• Oborne, D.J., Ergonomics at Work: Human Factors in Design and
Development, John Wiley & Sons, New York, 1995.
• Corlett, E.N., Clark, T.S., The Ergonomics of Workspaces and Machines,
Taylor & Francis, London, 1995.
• Proctor, R.W., Van Zandt, T., Human Factors in Simple and Complex
Systems, CRC Press, Boca Raton, Florida, 2008.
• Dhillon, B.S., Human Reliability with Human Factors, Pergamon Press,
New York, 1986.
• Dekker, S., Ten Questions about Human Error: A New View of Human
Factors and System Safety, Lawrence Erlbaum Associates, Mahwah,
New Jersey, 2005.
• Dhillon, B.S., Human Reliability, Error, and Human Factors in Power
Generation, Springer, London, 2014.
• Sanders, M.S., McCormick, E.J., Human Factors in Engineering and
Design, McGraw-Hill, New York, 1993.
• Dhillon, B.S., Human Reliability, Error, and Human Factors in Engineering
Maintenance, CRC Press, Boca Raton, Florida, 2009.
6 Safety, Reliability, Human Factors, and Human Error

• Strauch, B., Investigating Human Error: Incidents, Accidents, and Complex

Systems, Ashgate Publishing, Aldershot, UK, 2002.
• Karwowski, M., Marras, W.S., The Occupational Ergonomics Handbook,
CRC Press, Boca Raton, Florida, 1999.

1.4.2 Journals
Some of the journals that from time to time publish articles that are directly
or indirectly concerned with safety, reliability, human factors, and human
error in nuclear power plants are listed below.

• Nuclear Safety
• IEEE Transactions on Power Apparatus and Systems
• IEEE Transactions on Power Delivery
• Reliability Engineering and System Safety
• Nuclear Energy and Engineering
• Nuclear Engineering and Design
• Journal of Korean Nuclear Society
• Power Engineering
• Nuclear Europe Worldscan
• Accident Prevention and Analysis
• Journal of Risk and Reliability
• IEEE Power and Energy Magazine
• International Journal of Reliability, Quality, and Safety Engineering
• Electric Power Systems Research
• Human Factors
• Applied Ergonomics
• International Journal of Man-Machine Studies
• Human Factors in Aerospace and Safety
• IEEE Transactions on Systems, Man, and Cybernetics
• Ergonomics
• IEEE Transactions on Reliability
• Human Factors and Ergonomics in Manufacturing
• International Journal of Power and Energy Systems
• IEEE Transactions on Industry Applications
• Journal of Quality in Maintenance Engineering
• Progress in Nuclear Energy
• Fusion Engineering and Design
Introduction 7

• Microelectronics and Reliability

• Atomic Energy
• IEEE Transactions on Nuclear Science
• International Journal of Energy Research
• Nuclear Engineer
• Transactions of the American Nuclear Society
• Safety Science
• Journal of Nuclear Science and Technology
• Annals of Nuclear Energy

1.4.3 Conference Proceedings

Some of the conference proceedings that contain articles that are directly or
indirectly concerned with safety, reliability, human factors, and human error
in nuclear power plants are listed below.

• Proceedings of the IEEE Conference on Human Factors and Power Plants

• Proceedings of the IEEE Conference on Human Factors and Nuclear Safety
• Proceedings of the International Topical Meeting on Nuclear Plant
Instrumentation, Controls, and Human-Machine Interface Technology
• Proceedings of the International Conference on Reliability, Maintainability,
and Safety
• Proceedings of the Annual Reliability and Maintainability Symposium
• Proceedings of the Human Factors and Ergonomics Society Annual Meeting
• Proceedings of the International Symposium on Advances in the Operational
Safety of Nuclear Power Plants
• Proceedings of the International Conference on Advances in Nuclear Power
Plants
• Proceedings of the International Conference on Nuclear Energy for New Europe
• Proceedings of the International Conference on Nuclear Engineering
• Proceedings of the IEEE International Conference on Systems, Man, and
Cybernetics
• Proceedings of the American Nuclear Society International Topical Meeting
on Probabilistic Safety Analysis
• Proceedings of the International Conference on Reliability, Maintainability,
and Safety
• Proceedings of the World Congress on Intelligent Control and Automation
• Proceedings of the International Conference on Design and Safety of
Advanced Nuclear Power Plants
8 Safety, Reliability, Human Factors, and Human Error

• Proceedings of the IEEE International Conference on Human Interfaces in

Control Rooms
• Proceedings of the European Photo Voltaic Solar Energy Conference and
Exhibition
• Proceedings of the International Scientific Conference on Electric Power
Engineering

1.4.4 Technical Reports

Some of the important technical reports that are directly or indirectly con-
cerned with safety, reliability, human factors, and human error in nuclear
power plants are listed below.

• Trager, T.A., Jr., “Case Study Report on Loss of System Safety Function
Events,” Report No. AEOD/C504, United States Nuclear Regulatory
Commission, Washington, DC, 1985.
• “Nuclear Power Plant Operating Experience,” from the IAEA/NEA
Incident Reporting System, Report, Organization for Economic
Co-operation and Development (OECD), 2 rue Andre-Pascal, 7575
Paris Cedex 16, France, 2000.
• WASH-1400, Reactor Safety Study: An Assessment of Accident Risks
in U.S. Commercial Nuclear Power Plants, U.S. Nuclear Regulatory
Commission, Washington, DC, 1975.
• “An Analysis of 1990 Significant Events,” Report No. INP091-018,
Institute of Nuclear Power Operations (INPO), Atlanta, Georgia,
1991.
• “An Analysis of Root Causes in 1983 and 1984 Significant Event
Reports,” Report No. 85-027, Institute of Nuclear Power Operations,
Atlanta, Georgia, July 1985.
• Kolaczkowshi, A., Forester, J., Lois, E., Cooper, S., “Good Practices
for Implementing Human Reliability Analysis (HRA),” Report
No. NUREG-1792, United States Nuclear Regulatory Commission,
Washington, DC, April 2005.
• Maintenance Error Decision Aid (MEDA), Developed by Boeing
Commercial Airplane Group, Seattle, Washington, 1994.
• McCornack, R.L., Inspector Accuracy: A Study of the Literature,
Report No. SCTM 53-61 (14), Sandia Corporation, Albuquerque,
New Mexico, 1961.
• Seminara, J.L., Parsons, S.O., Human Factors Review of Power Plant
Maintenance, Report No. EPRI NP-1567, Electric Power Research
Institute, Palo Alto, California, 1981.
Another random document with
no related content on Scribd:
administraçion y gouierno deste
mundo inferior para el
cumplimiento de su neçesidad.
Estos no tienen composiçion ni
admistion en sí, ni ay materia que
se rebuelua con ellos estando en
su perfeçion; y ansi te hago saber
que los elementos simples y
puros no los podeis los honbres
vsar, tratar, ni comunicar sino os
los dan con alguna admistion. El
agua sinple y pura no la
podriades beber sino os la
mezclasse naturaleza con otro
elemento para que la podais
palpar y gustar; y ansi se ha de
entender del fuego, ayre y tierra;
que si no estuuiessen mezclados
entre si no los podriamos
comunicar. Pues ansi como el
puro elemento no tiene materia ni
conposiçion en sí, menos la
tienen los çielos, estrellas,
planetas, luna y sol. Tubo
neçesidad el mundo de luz en el
dia, y para esto formó Dios el sol.
Tubo neçesidad de luz en la
noche, y para esto formó luna y
estrellas. Tubo neçesidad de
ayuda para la comun naçençia y
generaçion de las cosas y
conseruaçion y para esto dio Dios
a los planetas, luna y sol y otras
estrellas y çielos virtud que en lo
inferior puedan influir para esta
neçesidad. Y passando por la
region de Eolo, rey de los vientos,
vimos vna gran multitud de almas
colgadas por los cabellos en el
ayre, y atadas las manos atras, y
muchos cueruos, grajos y milanos
que uibas las comian los
coraçones; y entre todas estaua
con muy notable dolor vna que
con gran furia y crueldad la
comian el coraçon y entrañas dos
muy poderosos y hanbrientos
buytres, y pregunté a mi genio
qué gente era aquella. El qual me
respondio que eran los ingratos
que auian cunplido con sus
amigos con el viento de palabras,
pagandoles con engaño y muerte
al tienpo de la neçesidad; y yo le
inportuné me dixesse quién
fuesse aquella desdichada de
alma que con tanto afan padeçia
entre todas las otras, y él me
respondio que era Andronico, hijo
del Rey de Vngria, el qual entre
todos los honbres del mundo fue
más ingrato a la belleza de
Drusila, hija del Rey de
Maçedonia; y yo rogandole
mucho que me dixesse en que
espeçie de ingratitud ofendio, se
sentó por me complazer y ansi
començó. Tu sabras que el Rey
de Albania y Morea hizo gran
exerçito contra el Rey de Lydia
por çierta differençia que entre
ellos auia sobre vnas yslas que
auian juntos conquistado en el
mar Egeo, y por tener el Rey de
Vngria antigua liga y deuida
amistad con el Rey de Albania le
enbió su hijo Andronico con algun
exerçito que le faboreçiesse, que
tenia ya su real asentado en la
Lydia, y vn dia, casi al puesto del
sol, saliendo Andronico del puerto
de Maçedonia en vna galera
ligera para hazer su xornada,
porque ya adelante auia enbiado
al Rey su gente, yendo ya a salir
del puerto casi a mar alta vio que
andaua por el mar vn vergantin
ricamente entoldado con la
cubierta de vn requemado
sembrado[710] de mucha pedreria
que daua gran resplandor a los
que andauan por el mar; y como
Andronico fue auisado del
vergantin mandó a los que yuan
al remo que se açercassen a él, y
yendose más açercando
reconoçieron más su riqueza y yr
damas de alta guisa alli; y asi
Andronico como al vergantin
llegó, por gozar de la presa
mandó afferrar, y luego saltó en él
y con muy gallardo y cortés
semblante se representó ante las
damas, y quando entre ellas vio a
la linda Drusila que en el mundo
no tenia par, que por fama tenia
ya notiçia della, y supo que se era
salida por alli a solazar con sus
damas sin caballero alguno, se le
humilló con gran reuerençia
ofreçiendosele por su prisionero;
y como él era mançebo y gentil
honbre y supo ser hijo del Rey de
Vngria, que por las armas era
cauallero de gran nonbradia, ella
se le rindio[711] quedando
conçertados ambos que acabada
aquella batalla donde yua bolueria
a su seruiçio, y se trataria con su
padre el matrimonio que agora
por palabras y muestra de
voluntad delante de aquellas
damas otorgaron entre sí;
confiando la donzella que su
padre holgaria de lo que ella
huuiese hecho, porque en el
estremo la deseaua conplazer; y
ansi dandose paz con algun
sentimiento de sus coraçones se
apartaron, y siguiendo Andronico
su xornada, ella se boluio a su
ciudad. Luego el dia siguiente
vinieron á Macedonia los mas
valerosos y prinçipales del reyno
de Traçia, enbiados por su Rey,
que estauan en vn confin y
comarcanos, los quales venian a
demandar al Rey de Macedonia
su hija Drusila por muger para el
hijo de su rey y señor; y lo que
suçedió, porque ya creo que
estás cansado de me oyr, y es
venido el dia, en el canto que se
sigue te lo diré. Por agora abre la
tienda y comiença a vender.

Fin de dozeno[712] canto del gallo

de Luçiano.
 NOTAS:
[682] G., contarme.
[683] G., que.
[684] Falta en el ms. R. este titulo.
[685] G., duodeçimo canto.
[686] G. (Tachado): Siguesse el dozeno canto del Gallo de
Luçiano, orador griego, contrahecho en el castellano por el
mesmo autor. (Antes se leia) interprete.
[687] G., incumbrada.
[688] G., enbiado.
[689] G., de vn habito.
[690] Al margen de este parrafo hay en el ms. G., una nota en
letra del siglo xvi, que dice: todo esto es lutheranismo.
[691] R. (Tachado), de azeyte.
[692] R. (Tachado), traeria.
[693] G., quieren.
[694] G., que.
[695] G., humedad.
[696] G., fortissimas.
[697] G., graçiosos.
[698] G., animales.
[699] G., intençion.
[700] G., trapazos de.
[701] G., pareçia.
[702] G., mi amor.
[703] G., a hazer su vaylia.
[704] G., vistieron.
[705] R., que.
[706] G., las que más se fatigan.
[707] G., traen.
[708] G., passemos.
[709] G., desuariar.
 ARGUMENTO
DEL
DEÇIMOTERÇIO
CANTO DEL
GALLO[713]

En el decimoterçio canto que se

sigue el auctor prosiguiendo la
subida del çielo descriue la
pena que se da a los
ingratos[714].

Gallo.—¡O malaventurados
ingratos, aborreçidos de Dios que
es suma gratitud!: ved el pago
que Dios y el mundo os da. Pues
ayer te dezia, Miçilo, cómo Drusila
no auia acabado de dar su fe y
palabra de matrimonio á
Andronico, quando la demandó
Raymundo, hijo del rey de Traçia,
por muger. Pues agora sabras
que ni cobdiçia de más señorio y
reynos, ni de más riquezas, ni de
más poder, la peruertio a que
negasse lo prometido a su
amante. Mas antes de cada dia
penaua más por él y le parecia
auer mucho más herrado y ser
digna de gran pena por auerle
dexado yr; y con esta firmeza y
intinçion respondio á su padre
descubriendole el matrimonio
hecho, al qual no podia faltar, y
como el padre la amaua tanto
despidió los enbajadores diziendo
que al presente no auia
oportunidad para el effecto de su
petiçion; y como el soberuio rey
de Traçia se vio ansi
menospreçiado, por ser el mas
poderoso rey que auia en toda la
Europa y por ser su hijo
Raymundo muy agraçiado
prinçipe y vnico heredero, y de
todas las prinçesas deseado por
marido. Pero por la gran ventaja y
valor de la hermosura de Drusila
la demandó á su padre por
muger, y quanto más se la
negaron más él se afiçionó a ella,
y ansi propuso con gran yra de la
conquistar por armas, de tal
suerte que quando ella no
pudiesse ser vençida a lo menos
perdiesse el reyno y neçesitarla
hazerlo por fuerça, avnque no con
intinçion de afrontar ni injuriar su
valerosa persona; y ansi luego se
lançó en el reyno de Maçedonia
con grande exerçito quemando,
talando y destruyendo todo el
estado; y la desdichada Drusila
quando vió á su padre y
hermanos con tanta afliçion,
llorando maldezia su triste hado
que á tal estado la auia traydo, y
no sabia con qué más cunplir con
ellos que con rogarles la
quitassen la vida, pues ella era la
ocasion y causa de aquella
tenpestad, y por muchas vezes se
determinó a se la quitar ella a sí
mesma, sino que temia el estado
miserable de la desesperaçion, y
hazer pessar a su querido y
amado Andronico, porque creya
çierto[715] dél que la amaua; y
ansi suçedió que en vna batalla
campal que les dio Raymundo,
por la gran pujança de esfuerço y
exerçito los vençió y mató al rey
de Maçedonia y dos hijos suyos.
De lo qual la desdichada Drusila
se sintió muy afligida y le fue
forçado huyr del enemigo y su
furia y recogerse en vn castillo
que era en el fin de su reyno en
los confines de Albania, que no
tenia ya más que perder; y alli
muy cubierta de luto y miseria
esperaua lo que della Raymundo
quisiesse hazer, teniendo por
mejor y más façil perder su vida,
pues ya la estimaua por muerte,
antes que perder al su Andronico
la fe; y estando ansi
desconsolada, huerfana y sola sin
algun socorro, vino nueua al
reyno de Albania cómo[716] el rey
de Lydia hauia vençido en batalla
a su rey y tenía preso a
Andronico, hijo del rey de Vngria;
y como Drusila tenia toda su
esperança en el fin de aquella
batalla, pensando que como della
saliesse vitorioso el rey de
Albania vernia con Andronico en
su fabor y que anbos bastarian
para la restituir en su reyno, como
ya se vió la misera sin alguna
esperança de remedio no hazia
sino llorar congojandose[717]
amargamente, maldiziendo su
suerte desdichada, no sabiendo a
quién se acorrer. No tuvo la
cuytada otra cosa de qué asir
para el entretenimiento de su
consolaçion sino considerar la
causa tan bastante que tenia
porque llorar, que le seria ocasion
de morir, y ansi de acabar su
dolor; y como Raymundo la
importunaba acortandola de cada
dia mas los terminos de su
determinaçion, ya como muger
aborrida, teniendo por çierto que
ningun suçeso podria venir que
peor fuesse que venir en manos
de Raymundo siendo vibo su
Andronico, determinó yr por el
mundo a vuscar alguna manera
como le libertar o morir en prision
con él; y ansi se vistio de los
vestidos de vno de sus hermanos,
y cortandose los cabellos
redondos al uso de los varones
de la tierra se armó del arnes y
sobre veste de su hermano sin
ser sentida, ni comunicandolo con
alguna persona, y un dia antes
que amaneçiesse se salió del
castillo sin ser sentida de las
guardas de fuera, porque a las de
dentro ella las ocupó aquella
noche como no la pudiessen
sentir; y ansi con la mayor furia
que pudo caminó para el puerto,
donde halló vna galera ligera que
estaua de partida para la Lydia,
en la qual se fletó pagando el
conueniente salario al piloto, y
con mucha bonança y buen
tenporal hizo su viaje hasta llegar
al puerto de su deseado fin.
Consolauasse la desdichada en
hollar la tierra que tenia en prision
todo su bien, y quando llegó a la
gran çiudad donde residia el rey
teniasse por muy contenta
quando via aquellas torres altas
en que pensaua estar secrestado
su amor, y ansi a la más alta y
más fuerte le dezia: ¡O la más
bienauenturada estançia que en
la tierra ay! ¿Quién te hizo tan
dichosa que mereciesses ser
caxa y buxeta en que estuuiesse
guardado el precioso joyel que
adorna y conserua mi coraçon?
¿Quién te hizo bote en que
ençerrasse conserua tan cordial?
¡O si los hados me conuertiessen
agora en piedra de tan feliz
edefiçio, porque a mi contento
gozasse de mi desseado bien! Y
diziendo estas y semejantes
lastimas, llorando de sus ojos se
entró en la çiudad y fuesse
derecha al palaçio y casa del rey,
y apeada de su cauallo se entró al
retraimiento[718] real, y puesta de
rodillas ante el rey le habló ansi.
Muy alto y muy poderoso señor, a
la vuestra alteza plega saber
cómo yo soy hijo del rey de
Polonia; y deseo de exerçitarme
en las armas para mereçer ser
colocado en la nonbradia de
cauallero me ha hecho salir de mi
tierra, y teniendo notiçia que tan
auentajadamente se platican las
armas en vuestra corte soy
venido a os seruir. De manera
que si mis obras fueren de
cauallero, ofreçida la oportunidad
terneme por dichoso tomar la
orden de caualleria de tan
valeloso principe como vos; y si
en vuestro seruiçio me reçebis me
hareis, señor, muy gran merçed.
Estauan delante la reyna y su hija
Sophrosina que era dama de gran
veldad, y el hijo del rey; y como
vieron a Drusila tan hermoso y
apuesto donzel á todos contentó
en estremo, y les plazió su
ofrecimiento, y a Sophronisa (sic)
mucho más; y despues que el rey
su padre le agradeçió su venida y
buena voluntad, le ofreçió todo
aquel aprouechamiento que en su
casa y reyno se le pudiesse dar.
Sophrosina le demandó a su
padre por su donzel y cauallero, y
su padre se le dió: y Drusila le fue
a bessar las manos por tan gran
merced: Sophrosina estaua muy
hufana de tener en su seruiçio vn
tan apuesto y hermoso donzel,
porque çiertamente ansi como en
su habito natural de muger era la
mas hermosa donzella que auia
en el mundo, y con su veldad no
auia cauallero que la viesse que
no la deseasse. Ansi por la
mesma manera en el habito de
varon tenia aquella ventaja que
toda lengua puede encareçer, en
tanta manera que no auia dueña
ni donzella que no deseasse
gozar de su amor; y ansi
Sophrosina dezia muchas veces
entre sí que si fuesse a ella çierto
que el su donzel era hijo del rey
de Polonia, como él lo auia dicho,
que se ternia por muy contenta
casar con él: tan contenta estaua
de su postura y veldad; y ansi en
ninguna cosa podia Sophrosina
agradar á Drusila que no lo
hiziesse de coraçon. Y un día
hablando delante de algunos
caualleros y reyna su madre, de
la batalla y de la muerte del rey
de Albania, vinieron á hablar de la
prision de Andronico hijo del rey
de Vngria, y la reyna dixo que
çiertamente seria justiçiado muy
presto, porque mató en la batalla
vn sobrino suyo hijo de su
hermana, y que su madre no se
podia consolar por la muerte de
su hijo sino con auer Andronico
de morir, y que para esto tenia ya
la palabra del rey; y como Drusila
esto oyó pensó perder la vida de
pessar, y con mucha disimulaçion
se puso a pensar cómo podria
libertar a su amante avnque ella
muriesse por él; y ansi como
Sophrosina se recogió a su
aposento pusosse Drusila de
rodillas ante ella suplicando la
hiziese vna merçed, haziendole
saber en cómo ella auia
conçebido gran piedad de
Andronico, por çertificarle la reyna
su señora que auia de morir. Que
le suplicaua le diesse liçencia
para le visitar y consolar porque
en ninguna manera se podria
sufrir a estar presente en la
çiudad a le ver morir. Sophrosina
como entendió esto haria a
Drusila gran plazer le dió luego vn
anillo muy preçiado que ella traya
en su dedo y le dixo que se
fuesse con él al alcayde del
castillo y le dixesse que se le
dexasse ver y hablar. No te puedo
encareçer el goço que Drusila con
el anillo lleuó, y como llego al
castillo y le mostró al alcayde y
reconoçió el anillo muy preçiado
de su señora Sophrosina: y por lo
que conoçia de los fabores que
daua al su donzel, luego le hizo
franco el castillo y le dió las
llaues, y sin mas conpañia ni
guarda le dixo que entrasse en la
torre de la prision. Como
Andronico sintió abrir las puertas
temiose si era llegada la hora en
que le auian de justiçiar, porque le
pareçió desusada aquella visita, y
estaua confusso pensando qué
podia ser; y avnque no tenia mas
prisiones que la fuerça de aquella
torre afligiale mucho la soledad y
el pensar la hora en que auia de
morir; y como Drusila entró en la
prision y reconoçío al su amado
Andronico, avnque flaco y
demudado todo, se le fue a
abrazar y bessar en la boca, que
no se podia contener; y como
Andronico se sintio ansi acariçiar
de vn mançebo en vn estado tan
miserable como aquel, estaba
confusso y turbado, sospechoso
que le llorauan el punto de su
muerte; y cuando ya su Drusila se
le dió á conoçer y boluió en sí no
ay lengua que pueda contar el
plazer que tuuieron anbos a[719]
dos. Luego le contó por estenso
cómo auia venido alli, y cómo
perdió sus padres, hermanos y
reyno, y el estado en que estaua
en el fabor de su señora
Sophrosina, y la confiança y
credito que se le daua en todo el
reyno[720], y cómo sabia
çiertamente que auia de morir y
muy breue, sin poderlo ella
remediar por ser muger; y que por
tanto conuenia que luego
tomando los habitos que ella
traya, que se los dio Sophrosina,
la dexasse con los que él tenia
vestidos en la prision, y que él se
fuesse a vuscar cómo la libertar.
En fin, pareçiendo bien a anbos
aquel consejo y siendo auisado
por Drusila de muchas cosas que
conuenia hazer antes que
saliesse de la çiudad: cómo se
auia de despedir de Sophrosina, y
cómo auia de auer su arnes,
vestiendose las ropas que ella
lleuaua, y tomando el anillo, y
çerrando las puertas de la torre se
salió, y dadas las llaues al
alcayde con mucha disimulaçion
se fue al palaçio sin que alguno le
echasse de ver por ser ya casi a
la noche, y entrando a la gran
sala halló a Sophrosina con sus
padres y corte de caualleros en
gran conuersaçion; y puesto de
rodillas ante ella le dio el anillo; y
por no dar Sophrosina cuenta al
rey ni reyna de ninguna cosa no
le habló en ello mas, pensando
que estando solos sabria lo que
con Andronico passó; y Andronico
sin mas detenimiento se fue al
aposento de Drusila conforme al
auiso que le dio, y vestido su
arnes y subiendo en su cauallo se
salio la puerta de la çiudad.
Esperó Sophrosina aquella noche
si pareçia ante ella el su donzel, y
como no le vio, venida la mañana
le enbió a vuscar, y como le
dixeron que la noche antes se
auia ausentado de la çiudad
penso auerlo hecho por piedad
que tubo de Andronico por no le
ver morir; y ansi trabajaua
Sophrosina porque se executasse
la muerte en Andronico
esperando[721] que luego bolueria
su donzel sabiendo[722] auerse
hecho justicia dél; y ansi se sufrió,
y respondia al rey y reyna quando
preguntauan por el, diziendo que
ella le enbió vna xornada de alli
con vn recado. Andronico con la
mayor priesa que pudo
caminando toda la noche se fue
para el rey de[723] Armenia,
porque supo que tenia gran
enemistad con el rey de Lydia, y
le dixo ser vn cauallero de Traçia,
que auia recebido vn gran agrauio
del rey de Lydia: que le suplicaua
le diesse su exerçito, y que él le
queria hacer su capitan general;
que él le prometia darle
façilmente el reyno de Lydia en su
poder, y que solo queria en pago
le hiziesse merced del[724]
despojo del palacio real y
prisioneros del castillo; y ansi
conçertados caminó Andronico
para Lydia con el rey de Armenia
y su exerçito, y salido el rey de
Lydia al campo con su exerçito le
mató Andronico en la[725] batalla
y le desuarató y[726] entró la
ciudad, y tomó en su guarda el
palaçio del rey, y se fue al castillo
y abierta la prision sacó de alli a
su Drusila con gran alegria y
plazer de anbos y gran gozo de
bessos y abrazos; y descubriendo
su estado y ventura a quantos lo
querian saber[727], vistio a Drusila
de habitos de dama, que
admiraua a todos su hermosura y
velleza; y poniendo en poder del
rey de Armenia á la reyna[728] y
todo el reyno de Lydia, y diziendo
que queria á Sophrosina para
darsela por muger a vn hermano
suyo la enbarcó juntamente con
todo el tesoro del rey. No huuieron
salido dos leguas del puerto
quando se les leuanta el mar con
tempestad muy furiosa; que[729]
despues de dos dias aportaron a
vna ysla sola y desierta y sin
habitaçion que estaua en los
confines de Rodas[730]; yua
Sophrosina muy miserable y
cuytada llena de luto, y Andronico
se la yua consolando, y como era
donzella y linda que no auia
cunplido catorce años bastó entre
aquellos regalos y lagrimas mouer
el coraçon de Andronico con su
hermosura y belleza; y ansi como
enhastiado de la su Drusila passó
todo su amor en Sophrosina: que
ya si a Drusila hablaua
comunicaua era con simulaçion,
pero no por voluntad; y ansi
fingiendo regalar á Sophrosina de
piedad, disimulaua su maliçia
encubierta, porque so color de
que la lleuaua para su hermano la
acariçiaua para si, pareçiendole
no ser aquella joya para
desechar, y ansi ardiendo su
coraçon con la llama que
Sophrosina le causaua, sospiraua
y lloraua disimulando su pena.
Pues llegados al puerto de la ysla,
como Drusila llegó cansada de las
malas noches y dias
passados[731] saltó luego en tierra
ya casi a la noche, y auiendo
çenado no queriendo Sophrosina
salir del nauio por su desgracia,
sacaron[732] al prado verde vn
rico pauellon con vna cama:
el[733] qual reçibió aquella noche
los desiguales coraçones[734] de
Andronico y Drusila en vno; y
como la engañada Drusila con el
cansancio se adormió, y el infiel
de Andronico la sintio dormida,
poco a poco sin que le sintiesse
se leuantó de la cama[735] junto á
la media noche y tomandola todos
sus vestidos la dexó sola y
desnuda en el lecho y se lançó en
el nauio; y ansi mandó a su gente
y marineros[736] que sin más
detenimiento leuantassen vela y
partiessen de alli, y con tienpo de
bonança y prospero viento
vinieron en breue a tomar puerto
en el reyno de Maçedonia,
algunas villas que avn estauan
por Drusila, porque Raymundo
era ydo a conquistar a Siçilia. La
desdichada de Drusila como de
su sueño despertó començó a
vuscar por la cama su amante,
estendiendo por la vna parte las
piernas, y por la otra echaua[737]
los brazos; y como no le halló,
como furiosa y fuera de seso saltó
del lecho desnuda en carnes y sin
sosiego alguno se fue a la ribera
adonde estaua[738] el nauio, y
como no le vio, presumiendo avn
dormir y ser sueño aquello que
via[739] se començó cruelmente a
herir por despertar; y ansi
arañando[740] su hermoso rostro
que el sol obscureçía con su
resplandor y mesando sus
dorados cabellos corria a vna
parte y a otra por la ribera como
adiuinando su mala fortuna. Daua
grandes bozes llamando su
Andronico; pero no ay quien la